Perioperative Immune Response Alternation. Can It Influence Cancer Recurrence?

The relationship between host immune response and tumor cells is currently defined by the immunoediting concept, including three phases: elimination, equilibrium and escape. Cancer cells are initially eliminated by the immune system, but progressively can develop escape mechanisms. The balance between elimination and escape depends on the prevailing activity of cytotoxic Th1 or immunosuppressive Th2 lymphocytes. Surgery has the potential to eradicate the disease, but, along with other perioperative circumstances, can induce a variable degree and period of immunosuppression. By modifying the Th1/Th2 ratio, these perioperative circumstances may favor the escaping mechanisms and, consequently, promote cancer recurrence and metastasis altering long term prognosis of cancer patients.

BLASTIC PLASMACYTOID DENDRITIC CELL NEOPLASM --A RAPIDLY EVOLVING ENTITY. CASE REPORT.

Blastic plasmacytoid dendritic cell neoplasm (BPDCN), CD4+/CD56+hematodermic neoplasm was formally known as blastic NK-cell lymphoma. It is in fact a form of acute myeloid leukemia notable for highly aggressive behavior with cutaneous, lymph node and bone marrow involvement. This entity is derived from plasmocytoid dendritic cells and has a predilection for extranodal sites, especially the skin. Elderly male patients are the most affected and the prognostic is poor. The first case was reported in 1994 and sice then, single cases and a few small series have been published. This article presents the case of a previously healthy 56-years-old man, who presented himself to a skin eruption consisting in multiple, large dermal ulcerated tumors, located on the trunk and scalp. The lesions were painless and grew in size rapidly. Physical examination was normal except for the skin lesions. Histological examination of a biopsy specimen and immunohistochemical studies (positive for next markers: CD4, CD 45, CD56, CD68, Ki 67) revealed the rare diagnostic-blastic plasmacytoid dendritic cell neoplasm.

PALLIATIVE TREATMENT OF MALIGNANT ESOPHAGOPULMONARY FISTULAS WITH COVERED SELF-EXPANDABLE METALLIC STENTS (SEMSS). A SINGLE CENTER EXPERIENCE.

AIM: The aim of our study was to determine the efficiency of SEMSs in patients with esophagopulmonary fistulas, regarding fistula closure, enhancement of dysphagia scores and survival rates. MATERIALS AND METHODS: Between January 2004 and June 2014, from a total of 133 patients who underwent stent placement procedures, 26 were diagnosed with esophagopulmonary fistulas. In 19 cases the fistulas were caused by esophageal carcinomas and in 7 cases by bronchogenic ones. 16 patients developed aspiration pneumonia, 3 lung abscess and 7 subclinical fistulas. RESULTS: Complete fistula sealing occurred in 26 patients (100%). There were no immediate procedural complications except chest pain in 5 cases. After sealing of the fistulas and antibiotic treatment, pneumonia has regressed. After stent insertion, the dysphagic syndrome improved significantly (mean dysphagia scores decrease from 3.28 to 1.3 after stent insertion). The main goal of palliative therapy in patients with unresectable cancer and esophago-pulmonary fistulas is to close the fistulas, thus preventing the aspiration of saliva and food into the bronchus. Other goals include amelioration of dysphagia symptoms, maintenance of oral intake and improvement of quality of life. Ultimately covered expandable metal stents may increase survival rate as compared with other therapies. CONCLUSIONS: The endoscopic placement of covered SEMSs is the treatment of choice for malignant esophago-pulmonary fistulas.

Corelation of lymphocytic infiltrates with the prognosis of recurrent colo-rectal cancer.

BACKGROUND: Recent studies are focusing on complementary prognostic and predictive markers that could complete the predictive TNM staging and one of the most promising directions is the study of tumor immune infiltrates. MATERIALS AND METHODS: Our 2-year retrospective study includes resection specimens from the primary tumors of 23 patients presenting to our clinic for a local or a distant relapse after colon or rectal cancer. From every primary tumor specimen we obtained immunohistochemically stained slides in order to assess cd3, cd4, cd8, cd45ro and cd68 infiltrates. Digital analysis assessed the density and percentage of positively stained cells in the normal peritumoral tissue, invasive margin and center of the tumor. RESULTS: A small density of cd8 positive cells in the peritumoral region was strongly correlated with a longer disease-free interval (p=0.009) and the Kaplan-Meier survival analysis showed that the percentage of cd8+ T cells could be used to stratify patients in terms of relapse risk (p=0.006). We found no correlation between invasion front infiltrates and intra tumoral infiltrates and the disease-free interval. CONCLUSION: Our study concludes that cytotoxic T-cell infiltrates in the normal peritumoral tissue could be used to predict a more aggressive tumor in terms of the relapse risk.

Total necrotizing colitis proximal to obstructive left colon cancer: case report and literature review.

BACKGROUND: Necrotizing colitis (NC) is a rare complication of the obstructive cancer of the left colon and it is the result of intramural ischemia due to impairment of blood supply secondary to increased endoluminal pressure. CASE PRESENTATION: A 70 years old patient with significant comorbidities (ASA 4) was admitted for intestinal obstruction.The extensive necrosis of the entire proximal colon secondary to an obstructive sigmoid colon cancer has been diagnosed intraoperatively. Total colectomy and terminal ileostomy have been performed. The postoperative course was uneventful and the ileostomy closure with ileo-rectal anastomosis was performed 7 months later. A review of the literature discussing the epidemiology, pathogenesis, diagnosis and therapeutic approach of this type of colitis, was performed. CONCLUSIONS: NC implies diagnosis and therapeutic difficulties,especially from point of view of surgical strategy. We advocate of large colic resections, beyond the macroscopic limits of the necrosis in order to avoid the postoperative complications. We also consider seriate surgical procedures as a good choice for the high risk patients.

Laparoscopic approach to ovarian dermoid cysts.

INTRODUCTION: Ovarian dermoid cysts (mature cystic teratomas) are a benign type of germ cell tumours and the most common ovarian neoplasms in women of fertile age. The aim of this study was to analyze the safety of the laparoscopic approach in ovarian dermoid cysts. METHODS: We performed a prospective study between 2006 and ' 2010 including 38 mature cystic teratomas treated either laparoscopically or by open access. All preoperative and postoperative data were included in an MS Access database and statistically analysed with SPSS v. 17 for Windows. RESULTS: The study group was divided into 2 subgroups according to the approach: laparoscopic (25 cases - 2 conversions) and classic (13 cases). The mean age of the patients was 40.34 years (range 19-74): 36.92 years for laparoscopic group and significantly higher 46.21 years for open approach group. Twelve cases were admitted as emergencies either because of complications (torsion or rupture of the teratoma) (11 cases) or associated with acute appendicitis (one case). The latter did not influence the decision for open or laparoscopic approach. Only 29 out of 38 cases had preoperative measurement of CA 125. CA 19-9 was performed in 27 cases and elevated levels were found in 21 cases (78%). Cysts over 10 cm presented higher values of CA 19-9. The mean cysts diameter was 11.29 cm (range 2-27 cm): 13.93 cm mean cyst diameter for open approach vs 9.75 cm for laparoscopic approach. The specimen removal required aspiration of the content for cysts bigger the 10 cm in laparoscopic approach. Mean hospital stay was 4.05 days (range 2-6 days) for the laparoscopic group, significantly lower when compared with the open approach group: 6.96 days (range 5-16 days). CONCLUSIONS: Laparoscopic management of ovarian dermoid tumours is a safe and efficient procedure. It does not increase complications rate in comparison with the open approach, offering a shorter hospital stay, a quick recovery and very important, it allows a conservative treatment, especially in premenopausal women who want to be pregnant.

[Right colon cancer--clinicopathological findings]. / Cancerul colonului drept--particularitati anatomo-clinice.

BACKGROUND: The right colon cancer (RCC) has some particularities from point of view of epidemiology, clinical aspects, therapy and prognosis. MATERIAL AND METHODS: We retrospectively analyzed the patients operated in the First Surgical Unit Iasi during 2004 until 2009, for right colon cancer. The patients' data from the medical files were digitally encoded and included into a MS Access database, and statistically analyzed. RESULTS: 219 cases were included into the analysis, which represents 24.17% from all the patients with colorectal cancer. The median age was 66 years old. A palpable mass into the right abdominal quadrant was founded in 41.5% and anemia in 65.3%. Abdominal ultrasound exam has been performed in all the patients, with 71.3% sensitivity for primary tumor positive diagnosis. Resectability was 89.5% but without multivisceral resections. The intraoperative complication rate was 6.8%; postoperative morbidity was 19.4% with an incidence of anastomotic leak of 1.38%. The postoperative mortality rate was 2.77%. The mean overall survival was 40.13 +/- 1.93 months (median: 49.26). The prognosis factors for the survival rate were: histologic type of the tumor, stage and tumor grading, vascular and perineural invasion. The presence of metastasis in more than 3 lymphnodes as well as resection of fewer than 11 lymphnodes were found as negative prognosis factors for the survival rate. CONCLUSIONS: RCC has an increasing incidence and it is associated especially with elderly patients. The RCC resectability is about 90% with acceptable rates of morbidity and mortality. Perineural and vascular invasion as well as rate of positive lymphnodes and count of resected lymphnodes are prognosis factor for overall survival rate.

[Small bowel tumours from barium meal to capsule endoscopy and from open to laparoscopic approach]. / Tumorile intestinului subtire de la tranzitul baritat la enteroscopie, de la abordul clasic la cel laparoscopic.

INTRODUCTION: Tumors of the small bowel are rare and present with nonspecific symptoms. That causes a significant delay in diagnosis and consequently a worse outcome for the patient. METHODS: In a retro-prospective study we evaluated a series of 63 patients with small bowel tumors operated in the First Surgical Clinic Iasi, during 1992-2010: 18 duodenal tumors, 26 jejunum tumors and 19 ileum tumors. There were 18 (28.6%) cases with benign tumors and 45 (71.4%) cases with malignant tumors (41 primary tumors and 4 secondary tumors). We discuss problems related to diagnosis, treatment and prognosis of these tumors in the presence of new explorations (capsule endoscopy, enteroscopy) and minimally invasive approach. RESULTS: Duodenal tumors were malignant in 14 cases (11 adenocarcinomas, 3 malignant GIST tumors) and benign in 4 cases (adenoma, lipoma, GIST tumor, schwannoma) which led to stenosis in 5 cases, upper gastrointestinal bleeding in 3 cases. Positive diagnostic was confirmed with barium meal and endoscopy. The jejunal and ileal tumors were mostly malignant 31 cases (13 carcinomas, 10 lymphomas, 2 malignant GIST and one sarcoma) with only 14 cases of benign tumors (5 GIST). Their tendency was to present as emergencies: 17 obstructions and 5 peritonitis. Modem imagistic proved useful as diagnostic tool: capsule endoscopy, CT-scan and enteroscopy. The benign tumors benefited from local resection (5 cases) and segmental enterectomy (12 cases), while malignant tumors were managed using Whiple's procedures (10 cases), duodenal-jejunal resections (1 case), segmental enterectomy (29 cases), ileocolectomy (2 cases) and three bypasses. Laparoscopic approach was performed in 8 cases. CONCLUSIONS: The incidence of small bowel tumors remains low. For diagnosis, CT-scan, enteroscopy and capsule endoscopy are very useful; unfortunately the last method is not practicable in emergency. Surgery is the best choice plus chemotherapy for some malignant tumors. Laparoscopic approach is feasible in selected cases.

Spiral enteroscopy--a novel method for the management of small bowel diseases--case report and description of technique.

Small bowel diseases are associated with difficult management. Recently, new methods such as single or double balloon enteroscopy and capsule endoscopy have been implemented for the investigation of small bowel, but none is perfect. Spiral enteroscopy seems to be an alternative primising technique for the diagnosis and therapy of small bowel diseases. We report two cases in which spiral enetroscopy was useful both for diagnosis and therapy. One was the case of a man with repeated digestive bleeding of unknown cause and spiral enteroscopy helped for diagnosis and treatment with argon plasma coagulation of the vascular lesions. The later was a patient with Gartner Syndrome with multiple duodenal and intestinal polyps and spiral enteroscopy allowed small bowel evaluation. In conclusion, this novel method seems to allow a rapid and efficient diagnosis of small bowel diseases.

Laparoscopic surgical education--the experience of the first surgical unit Iasi.

The classic apprenticeship model for surgical training takes place into the operating theater under the strict coordination of a senior surgeon. During the time and especially after the introduction of minimally invasive techniques as gold standard treatment for many diseases, other methods were developed to successful fulfill the well known three stages of training: skill-based behavior, rule-based behavior and knowledge-based behavior. The skills needed for minimally invasive surgery aren't easily obtained using classical apprenticeship model due to ethical, medico-legal and economic considerations. In this way several types of simulators have been developed. Nowadays simulators are worldwide accepted for laparoscopic surgical training and provide formative feedback which allows an improvement of the performances of the young surgeons. The simulators currently used allow assimilating only skill based behavior and rule-based behavior. However, the training using animal models as well as new virtual reality simulators and augmented reality offer the possibility to achieve knowledge-based behavior. However it isn't a worldwide accepted laparoscopic training curriculum. We present our experience with different types of simulators and teaching methods used along the time in our surgical unit. We also performed a review of the literature data.

Mean number of lymph nodes in colonic cancer specimen: possible quality control index for surgical performance.

UNLABELLED: Lymphatic involvement in colonic cancer explains the need for extensive lymphadenectomy for intended curative operations. Surgical skills may determine the actual extent of the procedure and indirectly the number of lymphnodes (LN) removed from each specimen. MATERIAL AND METHODS: We looked on a series of 329 consecutive patients with colonic cancer who underwent a standardized procedure including extensive lymphadenectomy. The main endpoints were survival as well as the number of LN and the mean number of RESULTS: Differences in Kaplan-Meyer survival curves between average and high performance colectomies have been identifled for right colectomies both in stage II (85.7% vs 64.7%) as well in stage III (71.4% vs 56.5% 5-year survival), and also in stage II for segmental colectomies (85.7% vs 78.9%), showing a definitive advantage in survival for patients operated by surgeons with a mean LN retrieval above cutoff values. CONCLUSIONS: our study suggests that the mean number of LN retrieved from the surgical specimen can be used to evaluate surgical performance in colonic cancer, and may reflect in postoperative survival. However care should be taken when extrapolating these data as surgeon-independent factors such as protocols for LN harvesting may be different in other institutions and will influence results.

Laparoscopic retrieval of gossypibomas--short series and review of literature.

UNLABELLED: Laparoscopic removal of retained abdominal foreign bodies represents an obscure domain of minimally invasive surgery. Although not an infrequent situation in general surgical practice, there are very few papers presenting laparoscopic approache in these circumstances. An iatrogenic foreign body following surgery, is a serious complication that may lead to medico-legal problem. We present our experience and a literature review. METHODS: In the last 20 years 48 patients with abdominal foreign bodies were referred to us. Out of these four gossypibomas were managed laparoscopically. RESULTS: Retained swabs represent the most common iatrogenic abdominal foreign bodies. Removal of gossypiboma present more problems in laparoscopic environment due to encapsulation and difficulties in localisation, as retained swabs unusually display radio-opaque markings. There was one conversion due to dense adhesion to the gastric wall. Postoperative recovery was uneventful in all cases. CONCLUSIONS: Gossypibomas, among abdominal foreign bodies, represent a certain reality with significant legal implications. Prevention should prevail and all efforts should be made in such respect. Laparoscopic approach is possible in selected cases (small swabs, encapsulated, no complications).

Laparoscopic management of gastrointestinal stromal tumours.

UNLABELLED: Gastrointestinal stromal tumours (GISTs) represent the most common non-epithelial tumour of the digestive tract. Laparoscopic approach may be considered ideal for the resection of these tumours. Their particular biological behaviour allows for a curative resection even without large resection margins and extensive lymphadenectomies. METHOD: Over a period of five years, eight patients benefited from laparoscopic resections (six patients with primary gastric GIST and two patients with small bowel GIST). Pathological features were analyzed including tumour size, surgical margin status, immunohistochemical staining profile, and tumour mitotic index. All cases were confirmed GISTs by immunohistochemical staining. RESULTS: The mean age of the patients was 61.6 years (range 48-71 years). Of these patients, five initially presented to hospital with acute gastrointestinal haemorrhage (four cases) or occult bleeding (one case). Gastric or small bowel tumours were identified during subsequent investigation. A presumptive diagnosis of gastric GIST was made in gastric lesions based on endoscopic, ultrasonic, and CT scan characteristics. Small bowel tumours were identified and presumed to be GIST based on information gathered from video capsule endoscopy, enteroscopy and CT scan. Complete resection was obtained with laparoscopic approach in six cases, while in two cases resection was laparoscopically assisted, with added oncology safety margins as preoperative definitive diagnosis was not available. Tumours varied in dimension from 2.5 cm to 9 cm and their malignant risk score using Fletcher criteria was low in three cases, intermediate in three cases and high in two cases. Mean postoperative stay was 3.8 days and there were no complications, nor postoperative mortality. After a mean follow-up of 26 months (range 1 to 60 months) all patients are symptom free and free of recurrent disease. CONCLUSIONS: A selective approach to laparoscopic resection of gastro-intestinal GISTs allows safe resection and very good results, on the condition that a clear diagnosis of GIST has been established on preoperative assessment. The laparoscopic feasible and safe considering the biological particularities of GIST, and it carries no additional risks.

Acute appendicitis--open or minimally-invasive approach?

BACKGROUND: Although laparoscopy has become the standard approach in other procedures, this technique is not generally accepted for acute appendicitis. AIM: To evaluate the results after minimally invasive appendectomies. METHODS: All medical records of patients operated for acute appendicitis during the last year were retrospectively reviewed. We considered only patients with diagnosis of acute appendicitis confirmed by histopathology. We designed two groups: operated by open approach (OA) and operated by minimally-invasive approach (MIA). The two groups were compared for differenced in homogeneity and main end results: morbidity, mortality, hospital stay. RESULTS: The men/women ratio was 112/88 (1.27), with a mean age of 31.83 +/- 1.06 years. There were more women in the MIA and more men in the OA group, p = 0.001. The Alvarado score was significant lower in MIA group (5.69 +/- 0.24 versus 6.57 +/- 0.23, p = 0.009). Comorbidities were noted in 51% from the patients, most of them in MIA group: 58.8%; N = 60, p = 0.016. Mean operation time was similar in both groups: 36.96 +/- 1.48 in OA versus 37.03 +/- 1.39 minutes in MIA. The postoperative mortality rate was 0.5%. The postoperative morbidity rate was 12%. Even though the number of cases with postoperative complications were double in OA group (16 cases versus 8 cases in MIA group) it did not reach statistical significance, p = 0.073. Histopathological examinations revealed early acute appendicitis in 45.5% cases (N = 91), suppurative appendicitis in 46.5% (N = 93) and gangrenous appendicitis in 8% (N = 16); early acute appendicitis was more frequent in MIA group and suppurative appendicitis in OA group: p = 0.017. The hospital stay was similar in both groups: 4.34 +/- 0.39 in OA versus 3.58 +/- 0.25 days in MIA group; p = 0.103. CONCLUSIONS: MIA is a safe procedure and can be performed even in the patients with comorbidities. We didn't find any statistical significant difference from point of view of postoperative morbidity; however more postoperative complications were find in OA vs MIA group. The postoperative hospital stay was similar in both groups.

Peritoneal tuberculosis in laparoscopic era.

UNLABELLED: Peritoneal tuberculosis is uncommon in developed countries, but as the general incidence of tuberculosis is on the rise in Romania so is the case with peritoneal localization of the disease. The present study retrospectively analyzed 18 patients (8 males and 10 females, mean age 50 years, range 17-74 years) diagnosed in our department with peritoneal tuberculosis between 1995 and 2007. RESULTS: Ascites was present in all but one case. Other common findings were weight loss (12 cases), weakness (5 cases), abdominal pain (16 cases), anorexia (6 cases) and night sweat (3 cases). Abdominal ultrasound has been used to demonstrate ascites in 16 cases. Only two patients had chest radiography suggestive for active tuberculosis. Laparotomy was performed in four cases, laparoscopy in 14 cases (two conversions). Intraoperative findings included multiple diffuse involvements of the visceral and parietal peritoneum, white "miliary nodules" or plaques, enlarged lymph nodes, ascites, "violin string" fibrinous strands, and omental thickening. Biopsy specimens showed granulomas, while ascitic fluid showed numerous lymphocytes. We conclude that the symptoms of abdominal tuberculosis vary greatly, and laparoscopy can be essential for diagnosis and management. The operation is safe, reliable with few complications and permits a prompt diagnosis, necessary to cure the patient.

Small bowel malignant melanoma--report of three cases and review of literature.

Malignant melanomas have a predilection to metastasize to the small bowel. Three patients with malignant melanoma involving the small bowel are reported. Two patients were operated on for small bowel obstruction and the third for gastrointestinal bleeding with anemia. Two patients remained well 6 month and 2 years, respectively, after surgery. One patient died of metastatic cerebral melanoma 6 months postoperatively. One should suspect small bowel metastasis in every patient with malignant melanoma in his past medical history, who presents with recent changes in bowel habits, intestinal obstruction or gastrointestinal bleeding. Preoperative assessment can only raise the suspicion, even with advanced imaging methods: capsule endoscopy, enteroscopy, CT or PET-CT. The only therapeutic procedure is surgical resection, offering both short term survival as well as an improvement in the quality of life. Although prognosis is dismal there are factors associated with prolonged survival: complete surgical resection with no residual primary or metastatic tumor, so-called primary small bowel tumors in patients aged more then 60 years, LDH < 200 U/L, lack of tumor spread in mesenteric lymph nodes.

Training on a virtual reality simulator--is it really possible a correct evaluation of the surgeons' experience?

UNLABELLED: Laparoscopic simulators provide a safe and efficient means of acquiring surgical skills. It is well known that virtual reality training improves the performance of young surgeons. Most of the virtual reality simulators have construct validity and can differentiate between novice and expert surgeons. However, for some training modules and trainees categories the possibility to distinguish the real surgeon's experience is still discussed. METHODS: A total of 14 young surgeons were evaluated during a 5 days postgraduate laparoscopic course using a LapSim Basic Skills, v. 3.0 simulator and a Virtual Laparoscopic Interface (VLI) hardware. The best performances of the surgeons were included in a MS Access database and statistical analyzed. RESULTS: There were 6 males and 8 women with a mean age of 30.21 +/- 1.01 years old (range 26-38). Nine surgeons (64.28%) were young residents without any laparoscopic surgical experience (group I), and the other 5, had some laparoscopic surgical experience (10 to 30 laparoscopic procedures) (group II). During the instrument navigation task we found that both hands performances were significant better in group II--the navigation time was 12.43 +/- 1.31 vs 19.01 +/- 1.40 seconds for the left hand--p = 0.006 and 13.57 +/- 1.47 vs 22.18 +/- 3.16 seconds for the right hand--p = 0.032); the right instrument angular path degree was also shorter for experienced surgeons (153.17 +/- 16.72 vs 230.88 +/- 22.6 - p = 0.017). The same data were noted for the lifting and grasping module. However, the suturing module tasks revealed contradictory results: the group I residents recorded better performances then the group II surgeons: total time--677.06 +/- 111.48 vs 1122.65 +/- 166.62 seconds; p = 0.043; right instrument path (m)--15.62 +/- 2.47 vs 25.73 +/- 3.13; p = 0.028; right instrument angular path (degree)--3940.43 +/- 572.54 vs 6595.5597 +/- 753.26; p = 0.017. CONCLUSIONS: Laparoscopic simulators are useful to evaluate the surgeons' experience; the parameters of the instrument navigation and lifting and grasping modules, which require a higher degree of eye-hand coordination, were better for residents with previous surgical experience and revealed a good transfer of training (TOT). The suturing module is less influenced by surgeons' experience. This result is probably explained by a lack of TOT.

[Surgical treatment of gynecomastia]. / Tratamentul chirurgical al ginecomastiei.

BACKGROUND: Gynecomastia describes a benign increase of the mammary gland in men. When medical treatment fails, the surgical procedure is the treatment of choice. There are two main surgical procedures: subdermal mastectomy and liposuction. AIM: To evaluate the results after surgical treatment (mastectomy) performed in a general surgery unit. METHOD: We performed a retrospective study; all the patients operated for gynecomastia were reviewed. The clinical, imaging, biological, intraoperative and histological data were included into a MS Access database and statistical analyzed. RESULTS: From 1990-2007, 114 patients were admitted in the First Surgical Clinic Iasi for gynecomastia. Only 12.6% from the patients were with bilateral gynecomastia. The mean age was 40.54 +/- 1.83 years old (range 12-84). Mean body mass was 26.72 +/- 0.46 kg/m2 (range 18.5-41), and about 20% from the patients had a BMI of over 30 kg/m2. We also noted that 46.5% were smokers. Simon classification was used for preoperative staging: 2.6% from the cases (N = 3) were included in stage I, 16.7% (N = 19) in stage IIa, 50% (N = 57) in stage IIb and 30.7% in stage III. The patients included in stages IIa and I are younger then the patients included in stage III (p = 0.024). Mastodynia was noted in 46 cases (40.4%). Ultrasound exam was performed in all the cases, and the larger diameter of the nodule measured was 3.75 +/- 0.18 cm (range 0.5-9.7). Only three cases were preoperatively treated with tamoxifen. Most of the cases were operated using general anesthesia (53.5%). Mastectomy was performed by peri-areolar (70.2%), elliptical (28.9%) or radial (0.9%) incisions. The subdermal mastectomy using peri-areolar approach was performed especially for the cases included in stages I, IIa and IIb--p < 10(-3). The epi-pectoral vacuum drainage has been used in 79.8%. The postoperative morbidity rate was 15.8%--4 cases of hematoma, 13 cases of seroma and 1 case complicated with skin necrosis. No specific risk factors for postoperative complications were found by univariate and multivariate statistical analysis. The pathological exam revealed pseudo-gynecomastia in 6 cases; the other cases presented dilated ducts. We also noted intraductal papillary hyperplasia in 87 cases and chronic inflammation in 35 cases. The histological exam also revealed intraductal papilloma--9 cases, fibro-adenoma--1 case, papillary ductal carcinoma--1 case and mucinous carcinoma--1 case. From all these data, the etiological diagnosis in presented series was: pseudo-gynecomastia--5.3% (N = 6), idiopathic--64.9% (N = 73), endocrine--7.9% (N = 9), drug induce--5.3% (N = 6), metabolic--7.9% (N = 9), tumoral--8.8% (N = 10). The postoperative hospital stay was 4.04 +/- 0.26 days (range 1-12). A literature review has also been performed. CONCLUSIONS: The management of gynecomastia has to be performed by a multidisciplinary team. Gynecomastia it is possible to be associated with a breast cancer, even in younger people. The surgical treatment, especially the type of incision, will be chosen from point of view of Simon stages. Liposuction can be associated in selected cases.

[Abdominal tuberculosis--a surgical reality]. / Tuberculoza abdominala--o realitate chirurgicala.

Abdominal tuberculosis is a rare disease, with non-specific findings. Peritoneal tuberculosis is a frequent cause of low gradient ascites. The records of 22 patients (Il males, 11 females, mean age 41,17 years, and range 17-74 years) diagnosed with abdominal tuberculosis (TBC) in First Surgical Clinic, "St. Spiridon" University Hospital Iasi between 1995 and 2006 were analyzed retrospectively and the literature was reviewed. From these 22 patients diagnosed with abdominal tuberculosis, there were: peritoneal TBC in 16 cases, intestinal TBC in 5 cases, mesenteric lymph nodes TBC in 1 case. The patients with intestinal TBC, were presented with complications, 2 perforations with peritonitis, 1 intestinal obstruction, and 2 as ileo-cecal "tumors" solved by right colectomy, 4 enterectomy (3 entero-enterostomies and 1 ileo-colic anastomosis). The patients with peritoneal TBC were diagnosed by laparoscopy and peritoneal biopsy in 13 cases, and by laparotomy in 3 cases. In peritoneal tuberculosis ascites was present in 15 cases. Other common findings were weight loss (12 cases), weakness (5 cases), abdominal pain (15 cases), anorexia (5 cases) and night sweat (2 cases). Only two patients had chest radiography suggestive of a new TBC lesion. In those patients with peritoneal tuberculosis, subjected to operation, the findings were multiple diffuse involvements of the visceral and parietal peritoneum, white "miliary nodules" or plaques, enlarged lymph nodes, ascites, "violin string" fibrinous strands, and omental thickening. Biopsy specimens showed granulomas, while ascitic fluid showed numerous lymphocytes. Post operatory evolution and management were applied by the TBC Medical System and the patients were treated 6 months by tuberculostatics, with favorable evolution. Abdominal tuberculosis should be considered for diagnosis, in patients with non-specific symptoms of abdominal pain, fever, loss of appetite, abdominal distension and even symptoms of acute abdomen. Laparoscopy is the best approach for peritoneal tuberculosis, and emergency surgery is necessary for acute complication like obstruction and peritonitis. Specific antituberculosis drugs are indicated in postoperative period.

Ovarian fibroma in the era of laparoscopic surgery: a general surgeon's experience.

The ovarian fibroma is a rare benign tumor originating from the connective tissue of the ovarian cortex. On occasion, the general surgeon may encounter ovarian fibroma while operating an acute abdomen. We present a series of 15 ovarian fibromas encountered in 13 patients over 11 years experience in our general surgical ward. Only four cases required emergency operations due to either tumors or adnexal torsion. High-resolution ultrasound scan with color Doppler suggested an ovarian fibroma in only ten cases, while CT and MRI were suggestive for the diagnosis in three other cases. Surgical treatment consisted of five ovarectomies, three adnexal resections and five total hysterectomies with bilateral salpingo-oophorectomy. Seven patients underwent laparoscopic surgery, four of them for an ovarian resection and in three for an adnexectomy. Laparoscopic approach has significant advantages by limiting parietal aggression with better cosmetic results, short hospital admission, lower costs, few postoperative adhesions and rapid recovery.